Provider Demographics
NPI:1467430751
Name:MAZSURE, LORI VAUGHAN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:VAUGHAN
Last Name:MAZSURE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26317 WEST WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803
Mailing Address - Country:US
Mailing Address - Phone:804-524-7744
Mailing Address - Fax:
Practice Address - Street 1:26317 WEST WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803
Practice Address - Country:US
Practice Address - Phone:804-524-7744
Practice Address - Fax:804-524-4718
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202205834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-0104Medicaid